Chapter 29: Management of Patients With Complications from Heart Disease

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) Bibasilar crackles b) Dependent edema c) Jugular vein distention d) Right upper quadrant pain

a) Bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

Which of the following is a key diagnostic indicator of heart failure (HF)? a) Brain natriuretic peptide (BNP) b) Creatinine c) Complete blood count (CBC) d) Blood urea nitrogen (BUN)

a) Brain natriuretic peptide (BNP) The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

A 78-year-old client has been diagnosed with right-sided heart failure from her symptomology. Her cardiologist will confirm his suspicions through diagnostics. Which of the following diagnostics are used to reveal right ventricular enlargement? Select all that apply. a) Chest radiograph b) Echocardiography c) Pulmonary arteriography d) Electrocardiogram

a) Chest radiograph b) Echocardiography d) Electrocardiogram An echocardiogram is usually performed to confirm the diagnosis of HF, identify the underlying cause, and determine the EF, which helps identify the type and severity of HF. This information may also be obtained noninvasively by radionuclide ventriculography or invasively by ventriculography as part of a cardiac catheterization procedure. A chest x-ray and an electrocardiogram (ECG) are obtained to assist in the diagnosis. Pulmonary arteriography is the one diagnostic tool here that does not apply.

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which of the following indicates that cardiac tamponade has been relieved? a) Decrease in central venous pressure (CVP) b) Decrease in blood pressure c) Increase in CVP d) Absence of cough

a) Decrease in central venous pressure (CVP) A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

Which of the following is the hallmark of systolic heart failure? a) Low ejection fraction (EF) b) Basilar crackles c) Limitation of activities of daily living (ADLs) d) Pulmonary congestion

a) Low ejection fraction (EF) A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient's symptoms.

A patient in cardiogenic shock after a myocardial infarction is placed on an intra-aortic balloon pump (IABP). What does the nurse understand is the mechanism of action of the balloon pump? a) The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. b) The balloon delivers an electrical impulse to correct dysrhythmias the patient experiences. c) The balloon keeps the vessels open so that blood will adequately deliver to the myocardium. d) The balloon will inflate at the beginning of systole and deflate before diastole to provide a long-term solution to a failing myocardium.

a) The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. The IABP uses internal counterpulsation through the regular inflation and deflation of the balloon to augment the pumping action of the heart. It inflates during diastole, increasing the pressure in the aorta during diastole and therefore increasing blood flow through the coronary and peripheral arteries. It deflates just before systole, lessening the pressure within the aorta before left ventricular contraction, decreasing the amount of resistance the heart has to overcome to eject blood and therefore decreasing left ventricular workload.

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero? a) 15 minutes b) 10 minutes c) 20 minutes d) 25 minutes

b) 10 minutes The survival rate decreases for every minute that defibrillation is delayed. If the patient has not been defibrillated within 10 minutes, the chance of survival is close to zero. The other options are too long of a time frame.

Ronald is a 46-year-old who has developed congestive heart failure. He has to learn to adapt his diet and you are his initial counselor. Which of the following should you tell him to avoid? a) Angel food cake b) Canned peas c) Dried peas d) Ready-to-eat cereals

b) Canned peas There are a wide variety of foods that Ronald can still eat. The key is they have to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. The key is to read the food labels and look for foods that contain <300 mg sodium/serving.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have? a) Class IV (Severe) b) Class I (Mild) c) Class II (Mild) d) Class III (Moderate)

b) Class I (Mild) Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) a) Jugular vein distention b) Cough c) Pulmonary crackles d) Ascites e) Dyspnea

b) Cough c) Pulmonary crackles e) Dyspnea The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

A patient with congestive heart failure is admitted to the hospital with complaints of shortness of breath. How should the nurse position the patient in order to decrease preload? a) Head of the bed elevated at 30 degrees and legs elevated on pillows b) Head of the bed elevated at 45 degrees and lower arms supported by pillows c) Prone with legs elevated on pillows d) Supine with arms elevated on pillows above the level of the heart

b) Head of the bed elevated at 45 degrees and lower arms supported by pillows Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient's weight on the shoulder muscles.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? a) Right atrial function b) Left ventricular function c) Left atrial function d) Right ventricular function

b) Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus? a) Measure the blood pressure in right arm as the client inhales slowly, then measure the blood pressure in the left arm as the client exhales slowly. b) Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. c) Measure blood pressure in the right arm, then in the left arm as the client slows the pace of his inhalations and exhalations. d) Measure blood pressure in either arm with the client holding his breath, then with the client breathing normally.

b) Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. To determine pulsus paradoxus, the nurse should measure blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Increased appetite b) Persistent cough c) Weight loss d) Ability to sleep through the night

b) Persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.

A client with stage IV heart failure has a living will indicating that he doesn't want to be placed on a ventilator. A nurse is caring for this client when he begins experiencing severe dyspnea. The nurse should: a) ask the client's family to consent to ventilator placement. b) administer oxygen, morphine, and a bronchodilator for client comfort. c) administer oxygen and hope the client will change his mind. d) call for respiratory therapy to intubate the client.

b) administer oxygen, morphine, and a bronchodilator for client comfort. A living will is a statement of a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect his wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will enable him to breathe more easily. The nurse shouldn't arrange for intubation without the client's consent or ask his family for permission to initiate mechanical ventilation.

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: a) urine specific gravity. b) weight. c) vital signs. d) fluid intake and output.

b) weight. Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.

A patient has missed 2 doses of digitalis (Digoxin). What laboratory results would indicate to the nurse that the patient is within therapeutic range? a) 4.0 mg/mL b) 0.25 mg/mL c) 2.0 mg/mL d) 3.2 mg/mL

c) 2.0 mg/mL For many years, digitalis (digoxin) was considered an essential agent for the treatment of HF, but with the advent of new medications, it is not prescribed as often. Digoxin increases the force of myocardial contraction and slows conduction through the atrioventricular node. It improves contractility, increasing left ventricular output.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? a) Intubation of the airway b) Insertion of a central venous catheter c) BP and pulse measurements every 15 to 30 minutes d) Hourly administration of a fluid bolus

c) BP and pulse measurements every 15 to 30 minutes Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.

The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following? a) Decreased O2 saturation levels b) Oliguria c) Pitting edema d) S3 ventricular gallop sign

c) Pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response.

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? a) Hyperactive bowel sounds b) High blood pressure c) Restlessness and confusion d) Increased urinary output

c) Restlessness and confusion Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? a) Implanted cardioverter-defibrillator (ICD) b) Pacemaker c) Ventricularassistdevice (VAD) d) Intra-aortic balloon pump (IABP)

c) Ventricularassistdevice (VAD) VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transport, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days.

A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals: a) postural hypotension. b) skin rash. c) peripheral edema. d) dry cough.

c) peripheral edema. Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

On his return to the cardiac step-down unit after his diagnostic procedure, a client awaits the report from his cardiologist. As the client's nurse, you review the process of measuring ejection fraction and explain to the client that it measures the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects? a) 45% b) 50% c) 40% d) 55%

d) 55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

You are caring for a client with left-sided heart failure. When you go in to do your shift assessment, you find your client is wheezing, restless, tachycardic, and has severe apprehension. You know that these are symptoms of what? a) Progressive heart failure b) Cardiogenic shock c) Pulmonary hypertension d) Acute pulmonary edema

d) Acute pulmonary edema Clients with acute pulmonary edema exhibit sudden dyspnea, wheezing, orthopnea, restlessness, cough (often productive of pink, frothy sputum), cyanosis, tachycardia, and severe apprehension. These symptoms do not indicate progressive heart failure, pulmonary hypertension, or cardiogenic shock.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? a) It never needs batteries. b) It's designed for extremely active patients. c) It's specifically designed for long-term use. d) An LVAD only supports a failing left ventricle.

d) An LVAD only supports a failing left ventricle. A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse? a) Administer epinephrine 1:10,000 10 mL IV push. b) Deliver breaths with a bag-valve mask. c) Defibrillate the patient with 360 joules. d) Call for help and begin chest compressions.

d) Call for help and begin chest compressions. Following the recognition of unresponsiveness, a protocol for basic life support is initiated. This includes activation of the emergency response team for help and performance of high-quality cardiopulmonary resuscitation (CPR), which includes beginning chest compressions.

A client has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next? a) Summon the nurse-manager. b) Administer potassium. c) Call the physician. d) Check the client's potassium level.

d) Check the client's potassium level. The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the physician. Because the client is taking furosemide (Lasix), a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the physician with a more complete database. The physician will need to be notified after the nurse checks the latest potassium level. Calling the nurse-manager is not indicated at this time. Administering potassium requires a physician's order.

Which drug is most commonly used to treat cardiogenic shock? a) Metoprolol (Lopressor) b) Furosemide (Lasix) c) Enalapril (Vasotec) d) Dopamine (Intropin)

d) Dopamine (Intropin) Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

Cardiogenic shock is pump failure that primarily occurs because of which of the following? a) Coronary artery stenosis b) Right atrial flutter c) Myocardial ischemia d) Inadequate tissue perfusion

d) Inadequate tissue perfusion The classic signs of cardiogenic shock are related to tissue hypoperfusion and an overall state of shock that is proportional to the extent of left ventricular damage. Reduced cardiac output and stroke volume reduces arterial blood pressure and tissue perfusion.